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jState of California—Environmental Protection Agency <br /> Form Approved OMB No,2050-0039(Expires 9-30-99) See Instructions on back t ge 6. Department of Toxic Substances Contrc <br /> Please print or type. Form designed for use on elite(12-pitch writer. Sacramento,California <br /> 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> I UNIFORM HAZARDOUS s net required by Federal law. <br /> ` WASTE MANIFEST ( Q I z �y Ga o(f <br /> t A. State Manifest Document Number. <br /> j 3. Generator's Name and Mailing Address 9 <br /> 645395 <br /> j i 3 t el V tM mo+a. <br /> B. Stile Generator's ID <br /> jh 4. Generator's Phone(1 �]y bu 3 yr s Ti at— j z <br /> N <br /> N 5. Transporter 1 Company Name 6. US EPA ID Number C. Slate Tromporror's ID[Reserved] <br /> h <br /> VAILI..l,v 1JY/�t�:l< (TIS. /A i.. 0 r] r) f{ e r P . D. Transporter's Phone V00-y:�+�.A(,,4 <br /> Loc? 7. Transporter 2 Company Name B. US EPA ID Number E. Stale Transporler's ID(Reserved.] <br /> � <br /> F. Tmnsporter's Phone'>i <br /> V G. Stale FF i 's ID <br /> Y Desi noted F iii N ms and Sil.Address 10. U5 EPA ID Number ty <br /> d F,.lM.: )uftkllr!( is <br /> 4L�Wlt�b- C $ U d3 8 t? 8 1114 U 3 <br /> ac +ra+,n ur, BTII RT H. facility's Phone <br /> o s ncr,,cn enl►zn Lt ;o v t; I r. ss>J-salela'�� <br /> �LL <br /> 12. Containers 13. Tolyl 14. Unit <br /> C"6 11. US DOT Description)including Proper Shipping Name,Hazard Class,and ID Number( No. T e Quantity WI/Vol 1. Waste Number <br /> Z Nr)N W',F3A.NAIA;F2r#lfj!tj WO%r,gTr 1 10111ff 17A <br /> € ; 0ILY 'IRATE11 F! ^ 1 T 'T ' <br /> 3 c (j d <br /> ly E b. Stale <br /> j o N <br /> ct <br /> c0, E EPA/cher <br /> v R <br /> j < A c State. If <br /> o T <br /> 00 O EPA/016i <br /> R <br /> w d. Slats <br /> t- <br /> w EPA/Other <br /> V <br /> w <br /> � J. Additional Descriptions far Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> { O 011:. Y WATER U1 b. <br /> I w <br /> a <br /> Z 15. Special Handling Instructions and Additional Information <br /> 0 <br /> a GL.OVF`; <br /> I w 17MERGIFNCY PHONE. 209.Hf:7 AfM7 <br /> j <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper ship ing name and are classified,packed, <br /> Vmarked,and labeled,and are in all respects in proper condition for transport by highway according to applica6le international and naliono government regulations. <br /> If I am a large quantity generator,I certify that I have a proggram in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economic 11 <br /> I d practicable and that I hhove selected the racticable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human health <br /> i and Ike environment;OR,if I am a small quantity generator,I have mode a good 61l effort to min' ize my waste generation and select the best waste management method that is <br /> zsc available to me and that I can afford. <br /> O _ <br /> Pr' 11/T ad Nome ,. /y Signvbr -. .. )pay r� <br /> ioZ <br /> w 7 17. Trans orter 1 Acknowledgement of Receipt of Materials <br /> I W S Print <br /> ma Signature r /7a °Yx. fab <br /> LL 0 18. Trans rter 2 Acknowled ement of Receipt of Materials <br /> iO I Printed/Typed Name Signature Month Day Year <br /> w E <br /> rn R <br /> V19. Discrepancy Indication Space <br /> Z F <br /> A <br /> C <br /> j20. FacilityOwner or Operator Certification of receipt of hazardous materials covered b this manifest except r noted In Item 19. <br /> j T Printed/Typed Name Signalum Month Day Year <br /> Y <br /> I <br /> ` DO NOT WRITE BELOW THIS LINE. <br /> Yellow: GENERATOR RETAINS <br /> i <br />